Captopril induced acute renal failure in a premature neonate
Captopril induced reversible acute renal failure in a premature neonate with double outlet right ventricle and congestive heart failure Lin-Hua Tan, Li-Zhong Du, Michael R. Carr, Julia K. Kuzin, Brady S. Moffett, Anthony C. Chang Houston, USA
and biochemical monitoring are suggested before and during captopril therapy. World J Pediatr 2011;7(1):89-91 Key words: acute renal failure captopril; congestive heart failure; neonate
Methods: We report a premature neonate with double outlet right ventricle and congestive heart failure who developed acute renal failure after administration of captopril at a low dose of 0.1 mg/kg per 8 hours. Results: On the third day after captopril therapy, the levels of serum creatinine and blood urea nitrogen increased to 2.6 mg/dl and 73 mg/dl respectively, and hyperkalemia appeared. Captopril was discontinued immediately. On the fourth day, the infant developed oliguria which persisted for 24 hours and resolved on the fifth day when the serum potassium normalized to 4.5 mmol/L. The level of serum creatinine peaked at 3.9 mg/ dL on the sixth day and gradually decreased to normal on the ninth day after administration of captopril. The captopril-induced acute renal failure resolved completely after cessation of the drug. Conclusions: Attention should be given to captopril therapy in premature neonates with congestive heart failure secondary to congenital heart disease with large left-to-right shunts. Routine hemodynamic examination
Author Affiliations: Department of Surgical Intensive Care Unit, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310003 China (Tan LH, Du LZ); The Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin, MC 19345-C, Houston, TX 77030 USA (Carr MR, Kuzin JK); Pediatric Cardiology, Department of Pharmacy, Texas Children's Hospital, 6621 Fannin, Houston, TX 77030 USA (Moffett BS); CHOC Heart Institute, Children's Hospital of Orange County, 455 S. Main Street Orange, CA 92868 USA (Chang AC) Corresponding Author: Anthony C. Chang, MD, MBA, MPH, CHOC Heart Institute, Children's Hospital of Orange County, 455 S. Main Street Orange, CA 92868 USA (Tel: 714-532-7576; Fax: 714-289-4962; Email:
[email protected]) doi:10.1007/s12519-011-0252-1 ©Children's Hospital, Zhejiang University School of Medicine, China and Springer-Verlag Berlin Heidelberg 2011. All rights reserved.
Introduction
C
ongestive heart failure (CHF) in early infancy is frequently related to high pulmonary blood flow and volume overload in the presence of congenital heart disease (CHD) with large left-toright shunts. In such patients, captopril, an angiotensin converting enzyme (ACE) inhibitor, is a rational drug choice for treatment. [1] Captopril is well tolerated in most patients. However, uncommon adverse effects such as acute renal failure (ARF) have been reported in pediatric patients with hypertension.[2] To the present, there is no report of acute deterioration in renal function after administration of captopril in neonates with CHF secondary to CHD with large left-to-right shunts. We report a premature neonate with CHF secondary to double outlet right ventricle (DORV) and large left-toright shunt developed ARF while receiving a low dose of captopril.
Case report
A 1600 g male infant was born via spontaneous vaginal delivery at 34 weeks gestation after an uneventful pregnancy. Apgar score was 9 both at 1 and 5 minutes. Shortly after birth, he was diagnosed with a tracheoesophageal cleft as well as DORV without chromosomal abnormality detected. He underwent placement of a gastrostomy tube and fundoplication at an outside institution. The infant was then transferred to our neonatal intensive care unit for further care at 18 days of life with a body weight of 2160 g. An echocardiogram revealed DORV with a subaortic ventricular septal defect,
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Case report
Background: Captopril is well tolerated in most patients. There is no report of acute deterioration in renal function after administration of captopril in neonates with congestive heart failure secondary to congenital heart defects with large left-to-right shunts.
World Journal of Pediatrics
80
Creatinine BUN 4
60
BUN (mg/dl)
6
Creatinine (mg/dl)
Case report
mild subvalvular and valvular pulmonary stenosis with a peak velocity of 2.1 m/sec and moderate right ventricular dilation. An electrocardiogram demonstrated right ventricular hypertrophy. A chest roentgenogram revealed mild to moderate cardiomegaly and increased pulmonary vascularity, consistent with excessive pulmonary blood flow. With the underlying cardiac structural abnormality and the above findings, the patient was diagnosed with CHF and pulmonary over-circulation secondary to DORV with large left-to-right shunt. He was initially treated with intravenous furosemide (1 mg/kg per dose, every 8 hours). However, CHF persisted, evidenced by clinical symptoms and elevated plasma B-type natriuretic peptide (848 pg/ml, normal
